By Alison L. Bailey, MD, FAACVPR, FACC | October 10, 2018

It is widely accepted that adverse psychological factors, such as depression and anxiety, are associated with cardiovascular disease (CVD). Conversely, positive psychological well-being — including positive thoughts and feelings, such as purpose in life, optimism and happiness — is independently associated with a lower risk of CVD and may promote cardiovascular health.¹

Ideal cardiovascular health is defined by the American Heart Association as the presence of ideal health behaviors and ideal health factors (Table 1).² Despite data that these factors are associated with improved CV outcomes, less than 10 percent of adults in the United States achieve these metrics.3 Negative non-CVD metrics, such as depression and cognitive decline, also increase with the number of uncontrolled health factors.

Table 1. Ideal Cardiovascular Health Metrics²

Can we achieve more ideal cardiovascular health if we improve psychological well-being? A recent article in the Journal of the American College of Cardiology reviewed the data on positive psychological well-being and cardiovascular disease.¹ This article is a must-read for all members of the cardiac rehab team.

We know that depression, anxiety, anger, hostility and post-traumatic stress disorder (PTSD) predict development of coronary heart disease.¹ A dose-response relationship can be seen and a combination of these negative factors confers cumulative risk. On the other hand, optimism appears to be protective for CVD. In a large prospective study of more than 70,000 women, those in the highest quartile of optimism had a 38 percent reduced risk of heart disease mortality and a 39 percent reduced risk of stroke mortality when compared to those in the lowest quartile.⁴ Additional studies have evaluated purpose in life and found a reduction in the relative risk for cardiovascular events.⁵

Psychological well-being may have direct effects that mediate improvements in cardiovascular health. Better psychological well-being is associated with lower BP, lower metabolic syndrome prevalence and more favorable lipids.^6-8 Numerous studies have documented an association between greater psychological well-being and a lower likelihood of smoking, a greater likelihood of regular exercise, consumption of more fruits and vegetables, and fewer sweets and processed meats.^9,10 It appears that better psychological well-being is associated with improved health behaviors and factors that are directly related to improved cardiovascular health. Whether this is a direct effect of a healthy lifestyle or vice versa, it is key to improving CV health.

Optimistic individuals are more likely to have strong social support networks, which may allow for traversing stressful situations better. Greater psychological well-being is associated with a greater capacity to self-regulate, which may allow for a greater ability at effective adaptation to challenges. Likewise, optimism may provide confidence about the future.¹ Combined, these traits may foster mechanisms that enhance cardiovascular health, such as acting on medical advice more readily, taking action to prevent bad events and being able to buffer inevitable social stressors that occur in daily life.

Interventions aimed at improving psychological well-being centered on skill-building and promotion of health could be helpful to promote healthy aging and improve cardiovascular health behaviors and factors — key goals of cardiovascular rehabilitation. Mindfulness-based programs that directly target optimism and positive affect can be helpful to CVD patients.¹¹  These programs can be delivered in individual or small group settings. Meditation is a key component of many interventions utilizing mindfulness and has been associated with improvements in health. Based on accumulating scientific data of its benefit, the AHA recently released a scientific statement recommending meditation as an adjunct to other cardiovascular risk reduction methods given the associated low cost and risk.¹² Mindfulness-based interventions have been associated with improvements across a range of physical and mental health outcomes, including improved depressive symptoms, anxiety, stress, quality of life, physical functioning, smoking cessation, healthy eating and physical activity in various groups of individuals.13-15 A meta-analysis of mindfulness-based stress reduction and mindfulness-based cognitive therapy in patients with vascular disease found that the interventions were associated with positive effects on stress during follow-up.¹⁶

Another method of improving psychological well-being is positive psychology interventions. These programs aim to promote optimism, gratitude and positive affect directly through activities such as imagining and writing about a better future, recalling positive life events, identifying and using personal strengths, and planning and performing acts of kindness.¹ Compared to mindfulness-based programs, these programs may not require as much provider training and are often straightforward to deliver. A recent analysis of 39 randomized trials found that positive psychological interventions were associated with significant effects on well-being and depression with sustained results.¹⁷

Cardiac rehab programs have been able to successfully integrate mindfulness-based interventions with positive outcomes.¹⁸ There is much rationale to support this combined psychological well-being and health behavior intervention in our programs. Cardiac patients could improve both by improving psychological factors linked to cardiac outcomes like depression and anxiety, as well as improving CV health behaviors and factors.

What does this mean for the CR professional?

Psychological well-being is an important component of a healthy lifestyle and can be improved by incorporation of mindfulness-based programs and positive psychology interventions. Cardiac rehab programs offer an ideal environment to improve cardiovascular risk factors, weight and physical inactivity by a variety of means and in a multidisciplinary manner. Interventions designed to improve psychological well-being should be considered in our cardiac rehab programs.

References

1. Kubzansky LD, Huffman JC, Boehm JK, et al. Positive Psychological Well-Being and cardiovascular Disease. J Am Coll Cardiol 2018;72:1382–96.
2. Lloyd-Jones DM, Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic impact goal through 2020 and beyond. Circulation 2010;121:586–613.
3. Younus A, Aneni EC, Spatz ES, et al. A systematic review of the prevalence and outcomes of ideal cardiovascular health in US and non-US populations. Mayo Clin Proc 2016;91:649–70.
4. Kim ES, Hagan KA, Grodstein F, et al. Optimism and cause-specific mortality: a prospective cohort study. Am J Epidemiol 2017;185:21–9.
5. Cohen R, Bavishi C, Rozanski A. Purpose in life and its relationship to all-cause mortality and cardiovascular events: a meta-analysis. Psychosom Med 2016;78:122–33.
6. Trudel-Fitzgerald C, Boehm JK, Kivimaki M, Kubzansky LD. Taking the tension out of hypertension: a prospective study of psychological wellbeing and hypertension. J Hypertens 2014;32:1222–8.
7. Richman LS, Kubzansky LD, Maselko J, Ackerson LK, Bauer M. The relationship between mental vitality and cardiovascular health. Psychol Health 2009;24:919–32.
8. Midei AJ, Matthews KA. Positive attributes protect adolescents from risk for the metabolic syndrome. J Adolesc Health 2014;55:678–83.
9. Grant N, Wardle J, Steptoe A. The relationship between life satisfaction and health behavior: a cross-cultural analysis of young adults. Int J BehavMed 2009;16:259–68.
10. Kelloniemi H, Ek E, Laitinen J. Optimism, dietary habits, body mass index and smoking among young Finnish adults. Appetite 2005;45:169–76.
11. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind in Everyday Life. New York, NY: Delacorte, 1990.
12. Levine GN, Lange RA, Bairey-Merz CN, et al. Meditation and cardiovascular risk reduction: scientific statement from the American Heart Association. J Am Heart Assoc 2017.
13. Ruffault A, Czernichow S, Hagger MS, et al. The effects of mindfulness training on weight-loss and health-related behaviours in adults with overweight and obesity: a systematic review and meta-analysis. Obes Res Clin Pract 2017;11:90–111.
14. Gotink RA, Chu P, Busschbach JJ, et al. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PLoS One 2015;10:e0124344.
15. Oikonomou MT, Arvanitis M, Sokolove RL. Mindfulness training for smoking cessation: a meta-analysis of randomized-controlled trials. J Health Psychol 2017;22:1841–50.
16. Abbott RA, Whear R, Rodgers LR, et al. Effectiveness of mindfulness-based stress reduction and mindfulness based cognitive therapy in vascular disease: a systematic review and metaanalysis of randomised controlled trials. J Psychosom Res 2014;76:341–51.
17. Bolier L, Haverman M, Westerhof GJ, Riper H, Smit F, Bohlmeijer E. Positive psychology interventions: a meta-analysis of randomized controlled studies. BMC Public Health 2013;13:119.
18. Griffiths K, Camic PM, Hutton JM. Participant experiences of a mindfulness-based cognitive therapy group for cardiac rehabilitation. J Health Psychol 2009;14:675–81.